A nurse is caring for a child with spina bifida.
Which intervention is most important?
Monitor for signs of infection.
Encourage mobility.
Provide nutritional support.
Maintain skin integrity.
The Correct Answer is D
Choice A rationale
Monitoring for signs of infection is crucial in children with spina bifida due to the potential for meningitis and urinary tract infections related to neurological deficits and potential openings in the spinal cord. Normal white blood cell count ranges from 4,500 to 11,000 per microliter, and fever, redness, swelling, or purulent drainage would indicate infection.
Choice B rationale
Encouraging mobility is important to promote development and prevent complications like contractures. However, in the immediate postoperative period or with significant neurological impairment, maintaining skin integrity takes precedence to prevent infection and further complications.
Choice C rationale
Providing nutritional support is essential for growth and development in children with spina bifida, who may have feeding difficulties or increased metabolic needs. Adequate nutrition supports overall health, but preventing skin breakdown in areas prone to pressure is a more immediate concern.
Choice D rationale
Maintaining skin integrity is the most important intervention because children with spina bifida often have sensory and motor deficits that make them susceptible to pressure ulcers, especially over bony prominences and the surgical site if a myelomeningocele repair has occurred. Skin breakdown can lead to serious infections and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Urinary tract infections can cause bladder irritation and dysfunction, leading to symptoms such as frequency, urgency, and nocturia, which can manifest as enuresis, especially secondary enuresis (bedwetting that starts after a period of dryness). Therefore, assessing for a UTI is a crucial first step to rule out a treatable medical cause. Normal urine specific gravity ranges from 1.005 to 1.030, and a urinalysis can detect the presence of bacteria, white blood cells, or nitrites indicative of infection.
Choice B rationale
Psychological stressors can contribute to enuresis, particularly secondary enuresis. Anxiety, family changes, or school-related stress can manifest physically. While important to explore, medical causes like UTIs should be ruled out first.
Choice C rationale
Sleep patterns are relevant in the context of enuresis, as bedwetting occurs during sleep. However, assessing for a medical cause like a UTI should precede a detailed evaluation of sleep habits.
Choice D rationale
A family history of enuresis can suggest a genetic predisposition. However, the immediate nursing priority is to assess for and rule out treatable underlying medical conditions, such as a urinary tract infection.
Correct Answer is D
Explanation
Choice A rationale
Pediculosis, an infestation of lice, is highly contagious through direct contact, especially head-to-head contact. Therefore, no precautions are insufficient to prevent the spread of lice to healthcare workers and other patients. Standard precautions are necessary.
Choice B rationale
Wearing a gown and hair cover is not typically required for routine care of a child with pediculosis. Standard precautions, including gloves to prevent direct contact with the child's hair and scalp, are generally sufficient. Gowns are usually indicated when there is a risk of contact with body fluids or secretions.
Choice C rationale
Isolating the child in a negative-pressure room is reserved for airborne infections, such as tuberculosis or measles. Pediculosis is transmitted through direct contact, not airborne droplets, so isolation in a negative-pressure room is unnecessary and inappropriate.
Choice D rationale
Wearing gloves is the appropriate nursing action when treating a hospitalized child with pediculosis. Gloves prevent direct contact with the lice and their eggs (nits) during examination and treatment of the scalp and hair, thus minimizing the risk of transmission to the healthcare worker. .
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